Renewed effort to lure doctors to rural areas faces obstacles

By Darryl Fears
Washington Post Staff Writer
Monday, August 9, 2010; A01

ESMONT, VA. -- Sarah Carricaburu slipped her sleek new iPhone into her purse for the day. With no signal here deep in the woods, it's useless. She swiveled away from her desktop computer, which can't access the Internet, and glanced at the manila folders of patient records neatly stacked on a shelf by nurses.

"I grew up in the age of electronic medical records," said Carricaburu, 33, a primary care physician who was raised in the Washington suburbs. "Coming here was like stepping back in time. I would like to stay in a community health-care setting, but here I didn't feel like I had the resources to do my job. You're cut off."

Carricaburu's choice of whether to stay or go is not just about her own career satisfaction. Her 12 colleagues at the Southern Albemarle Family Practice have a vested interest in her staying on, as the clinic's director and its one full-time physician, beyond the three years that she is under a contract with the federal government that will help pay off school loans. She is also a test case for the Obama administration's goal, under the new health-care law, to bring thousands of young primary care doctors to underserved areas such as this unincorporated town of 1,200 -- and keep them there.

The administration recently invested more than $1 billion from the stimulus and the health-care law into the National Health Services Corps to beef up doctor recruitment. It's more money than the 40-year-old agency has ever had, said Rebecca Spitzgo, associate administrator for the Bureau of Clinician Recruitment and Service.

Nearly 5,000 recent medical school graduates accepted federal grants to pay off tuition and school loans averaging $150,000 per student. The awards come with contracts that obligate the young doctors to remain in what are typically rural areas for three to five years. The corps hopes to recruit another 2,800 students next year. A report by the corps' advisory council estimated that 27,000 primary care physicians are needed to meet the needs of about 45 million Americans in medically underserved areas.

But after facing decisions similar to the one Carricaburu is weighing, several young doctors who were interviewed said they are struggling with whether to spend a career in rural settings. Experts said they expect retention to be a problem.

Carricaburu embodied the traits that President Obama extolled in stump speeches about reform. She earned straight A's through Richard Montgomery High School in Rockville and graduated from Johns Hopkins University with a 3.7 grade-point average. She was one of two students in her graduating class at Northwestern University's Feinberg School of Medicine who chose to become a family practitioner rather than one of the high-wage specialists the school is known for producing.

Carricaburu made that choice despite the stigma that others attach to students who choose family medicine. "When I told one of my professors that it was what I wanted to do, he said, 'You're too smart for that.' "

But Carricaburu had a mission. "I just always felt that I really wanted to help people who wouldn't otherwise get help," she said. "It's like a cliche, but it's true."

Daily inconveniences

The Southern Albemarle Family Practice, where Carricaburu sees about 18 patients daily, sits a few miles from the real-life Walton's Mountain, made famous by the TV show about a homespun family that lived there.

It's surrounded by trees as tall as skyscrapers, emerald soybean farms and vineyards. To get there from her townhouse in Charlottesville, about 46 miles round trip, Carricaburu takes a two-lane highway that curves and dives on sloping hills, and a one-lane bridge where crossing cars are blind to oncoming traffic.

Carricaburu directs a staff of 12, including two part-time doctors. She said she enjoys the work. On a Thursday, she examined patient Edwin Denby, 70, who got careless while doing yardwork and poked his eye on a bush. Next, she played with Nikisha Woody's 1-year-old son Jordan as he romped through the examination room.

But she was unprepared for the daily inconveniences of rural living: well water in the clinic's kitchen sink that smells of rotten eggs; being unable to use the iPhone's Epocrates app, which helps doctors identify and prescribe medicine; the dial-up Internet that crawls along on a single computer shared by the clinic; the 40-minute drive to a grocery store; the lack of dating potential.

"I don't think I'm a rural kind of person," Carricaburu said. "I like having stuff around. I like the ability to go out to dinner and do cultural things."

The National Health Service Corps should make rural offices more friendly to technologically savvy young doctors if it wants them to stay, she said.

A three-year federal contract that provided Carricaburu with $50,000 to help pay off $200,000 in school-related debt will expire in September 2011. As she decides her future, Deborah Anderson, an assistant manager at Southern Albemarle, and administrators at Central Virginia Health Services, its parent organization, watch anxiously.

Doctor turnover in rural Virginia clinics creates a void in services. Patients who develop a relationship with doctors feel rejected and are reluctant to bond with new doctors.

"Patients have been very hesitant and angry," Anderson said. "The typical question they ask new doctors is, 'How long are you going to stay?' They are very reluctant to get to know new doctors."

The staff does not want Carricaburu to leave. "We were a little worried about her personal life," Anderson said.

Colleagues' concerns

The staff had a reason to worry.

Before Carricaburu arrived at the Southern Albemarle Family Practice in August 2008, when there was no full-time doctor, "we had to let patients go," said M. Denise Williams, a doctor who works three days a week.

In Esmont and hundreds of other areas where doctors are scarce, the impact can be devastating. Residents delay examinations until conditions are chronic and more costly to treat, doctors and nurses said. Diabetes leads to amputations and heart conditions lead to strokes.

With so much at stake, the clinic's staff members started to pay close attention to Carricaburu. They made mental notes when she expressed concern, here and there, about the long trip from Charlottesville, about the lack of basic technology, about not meeting guys.

Workers at the clinic couldn't rely on the National Health Service Corps' attempts to brighten the lives of isolated workers: connecting young doctors through the Internet and such. Carricaburu could barely log on to the Internet, and she didn't read beyond the first few chapters of the book the corps gave her. In "Transforming Burnout: A Simple Guide to Self-Renewal," the author loftily counsels doctors to overcome their doldrums by finding spiritual meaning in their work.

Williams and another part-time doctor, Margaret Hobson, took action. They set Carricaburu up on dates. The first guy, introduced by Williams early this year, "just didn't work out," she said. But Hobson's recommendation -- Rick Regan, a corporate pilot who lives near Front Royal -- turned Carricaburu's head.

Whenever he visits Charlottesville, about three times a week, Carricaburu beams. After a recent Wednesday visit, Carricaburu smiled a little more as she walked the halls.

In a perfect scenario for the Southern Albemarle staff and the Obama administration, Carricaburu and Regan would fall in love, marry and settle in Esmont or nearby Buckingham County, as Williams did years ago with her husband.

But Williams realizes that Carricaburu, who enjoys museum hopping and in-line skating, is not entirely like her.

"I kind of like being a small- town doctor," said Williams, 58.

Williams has made her career part of her small-town life, priding herself on knowing patients by their first names, making house calls and dabbling in local politics. Her subscription to the New Yorker is about as close to the big city as she gets.

On a Wednesday, all the patients in the clinic's waiting room were there to see Williams. "She knows every single person who comes here," said Tracy Armstrong, 45, a patient. "She knows everyone in town. She's very professional, but also knows how to deal with people who are hesitant to come in here. She's amazing."

When a laborer named David Strong burst through the door, blood oozing from a hand that he had accidentally sliced open with a box cutter, Williams stitched him up. Strong, 37, grimaced and squirmed in his soiled muscle shirt, and Williams gave him a no-nonsense stare.

"I thought you were tough," she said.

When the workday ended, paper medical records from the visits piled up in Williams's office. It took her three hours to record them. Electronic records would shorten her hours, Williams acknowledged, but she dreads the training it would take to learn to use them.

And she dreads having an increased workload at the clinic if Carricaburu leaves. Williams sees about 20 patients a day, equal to Hobson. They would have to see some of Carricaburu's 18 patients in her absence.

"Dr. Hobson and I just couldn't handle it," Williams said.

Through the health-care overhaul, the Obama administration has worked to lighten their load with doctors such as Carricaburu, but nobody at the clinic is sure that the situation will work out. Carricaburu said that she admires Williams and Hobson, but that she's simply not like them. She needs different tools.

"The other doctors are older. They learned stuff on the job," she said. "That's not how I was trained. I feel like I'm going backward."

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